Ask a doctor to describe a typical day’s work and her answer will likely sound significantly different than it would have a generation ago. While the need for medical care hasn’t changed much, technology has evolved the way we provide it.
The same cannot be said for the job of a histotechnologist. Also called a histologic technician, these trained and certified professionals are responsible for processing biopsied tissue samples to prepare them for interpretation and eventual diagnosis. It’s an arduous, high pressure job that hasn’t changed much since it originated more than a century ago. Histotechnologists face unrelenting workloads and there are fewer of them to do the work, adding to the strain of keeping up and avoiding mistakes that could have disastrous consequences.
According to the New York State Clinical Laboratory Association (NYSCLA), more than half of the state’s 339 licensed histologic technicians (2020 numbers) are over age 55. As many face retirement, the workforce will continue to dwindle and there are fewer entering the profession to replace them. NYSCLA also recently reported that just 33 new histotechnologists were licensed in New York state last year.
“The histotechnologist labor shortage is a national crisis, not unique to any one state,” said Dr. James Crawford, senior vice president of Laboratory Services at Northwell Health. “It’s a problem that’s 20 to 30 years in the making, and we’ve reached a tipping point. Patient care depends on pathology and it’s delayed because of these shortages. We need to take action to support this workforce.”
Revolutionizing the notoriously stressful role of a histotechnologist may help to attract interest in the profession and make the work for current techs not only more rewarding, but also more accurate, ultimately leading to better care for patients.
Automation can help. Let’s take a look.
Time Better Spent?
Histotechnologists are an important component of clinical lab teams and their work is instrumental to healthcare. In fact, according to the Centers for Disease Control and Prevention (CDC), 70% of today’s medical decisions depend on test results processed by labs.
Processing tissue samples is tough and manual, but it’s not plug-and-play work. It requires skilled handling of delicate tissue samples and includes logging, chemical processing, cutting, mounting and staining procedures, ensuring each step is handled with precision and aligned with lab orders that vary based on tissue type and patient.
An 8-hour lab shift for a histotechnologist may start as early as 3:00 AM, or alternatively stretch late into the evening hours. The job requires both collaboration as well as total focus on one’s individual tasks. It looks something like this:
When a patient’s tissue samples arrive at the lab, often as a package of seven or eight individual specimens, the case is assigned an accession number, and each specimen a separate specimen number. The tissue samples are examined at the grossing bench to identify physical characteristics, such as color and size. For biopsies, the worker, who could be either a histotechnologist or a pathologists’ assistant, places the specimens into labeled plastic cassettes. More complex specimens (such as larger specimens obtained at surgery) are examined and dissected by pathologists’ assistants or pathologists; tissue samples are also then placed into labeled plastic cassettes. Next, the cassette is subjected to an automated series of chemical steps to preserve and dehydrate the tissue samples, and then permeated with paraffin wax, generating what is called a “block.”
From here a process called microtomy comes into play. Histotechnologists often refer to it as the backbreaking part of their work. It involves using a manual slicing machine, called a microtome, to cut extremely thin slices from each block – the slices are typically four to five microns in thickness. It takes tremendous skill—a cut too thin or too thick can impair microscopic interpretation by the pathologist. The fragile slices are then transferred to a temperature-controlled water bath and lifted out with glass slides that will then be moved to additional automated processing stages before they can be examined by microscopy.
A skilled histologic technician performs microtomy on about 18,000 to 20,000 paraffin blocks per year. The workload is only expected to increase, owing to the aging of our population and the increasing burden of diseases that need pathology examination.
How Automation Can Help Evolve the Profession
Not only is a histotechnologist’s work arduous and repetitive, the manual nature of the work creates the potential for errors. An error on their part—especially specimen mislabeling or specimen swapping—could have serious consequences. It can lead to missed diagnoses, or a diagnosis made on the wrong patient. The skillset-based manual workflow also introduces variability in the quality of microtomy with regards to section thickness, microtome “chatter,” and the frequency of the water bath-introduced artifacts of tissue folding, tears, and fragmentation. Since the 1880’s, these multiple quality issues have persisted without substantive improvement through the 140 years of traditional histology. Although a pathologist reviewing suboptimal tissue sections can usually see through the quality artifacts and render accurate diagnoses, the advent of digital pathology and artificial intelligence-assisted histopathologic interpretation demand a higher standard for reliable histology quality.
While automated technologies have successfully addressed the pre- and post-microtomy steps of tissue processing, actual microtomy has almost entirely remained a manual procedure.Automated microtomy that retains the water bath step has been introduced, but does not eliminate the water bath-introduced quality artifacts. Automating microtomy that eliminates the water bath step can create quality standardization and bring consistency to the practice of histopathology. Such standardization then empowers digital pathology, with its vast capabilities for artificial intelligence-assisted diagnostics, portability of pathology practice, 3D tissue imaging, and molecular morphology that can link pathology with genomic and proteomic biomarkers.
Automation can also help to address the growing histotechnologist labor shortage, while also enhancing their job functions towards oversight of the automated histology laboratory and doing important off-production special microtomy work, rather than the monotony of the main production line of 20,000 blocks per year. This transformation of workflow can return histology laboratories to a state of balance in support of reliable production of high-quality histopathology.
In addition, by freeing histotechnologists from the monotony of the production line and enabling them to focus on the more complex tasks of histology (including the role of digital pathology, teaching and mentoring, and research), we can help advance a profession that is long overdue for transformation.